What is the recommended dosage of Eliquis (apixaban) for patients requiring anticoagulation?

Apixaban (Eliquis) Dosage Recommendations

The recommended dosage of apixaban varies based on the indication, with standard dosing for atrial fibrillation being 5 mg twice daily (with specific dose reductions to 2.5 mg twice daily for certain populations), while VTE treatment requires 10 mg twice daily for the first 7 days followed by 5 mg twice daily. 1, 2, 3

Dosing by Indication

Atrial Fibrillation

• Standard dose: 5 mg orally twice daily 2, 3
• Reduced dose (2.5 mg twice daily) for patients with at least two of:
  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL 2, 3

Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Treatment

• Initial treatment: 10 mg orally twice daily for the first 7 days
• Maintenance treatment: 5 mg orally twice daily after the initial 7 days 1, 3
• Extended treatment: After at least 6 months of therapy, either continue 5 mg twice daily or reduce to 2.5 mg twice daily 1, 2, 3

DVT Prophylaxis (Following Hip or Knee Replacement)

• 2.5 mg orally twice daily 3
• Initial dose should be taken 12-24 hours after surgery
• Duration: 35 days for hip replacement; 12 days for knee replacement 3

Special Populations and Considerations

Renal Impairment

• No dose adjustment needed for mild to moderate renal impairment
• For patients with end-stage renal disease on hemodialysis: 5 mg twice daily, reduced to 2.5 mg twice daily if age ≥80 years or body weight ≤60 kg 2
• Canadian labeling specifies 2.5 mg twice daily if serum creatinine ≥133 μmol/L and either age ≥80 years or body weight ≤60 kg 2

Drug Interactions

• For patients receiving 5 mg or 10 mg twice daily, reduce dose by 50% when coadministered with combined P-gp and strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, ritonavir) 3
• For patients already taking 2.5 mg twice daily, avoid coadministration with combined P-gp and strong CYP3A4 inhibitors 3

Temporary Interruption for Surgery

• Discontinue apixaban at least 48 hours prior to elective surgery with moderate/high bleeding risk
• Discontinue at least 24 hours prior to procedures with low bleeding risk 3
• Resume after adequate hemostasis has been established 3

Important Warnings and Precautions

• Premature discontinuation increases thrombotic risk: If discontinued for reasons other than pathological bleeding or completion of therapy, consider alternative anticoagulation 3
• Missed doses: Take as soon as possible on the same day and resume twice-daily schedule; do not double dose 3
• Spinal/epidural hematoma risk: Consider timing between apixaban administration and neuraxial procedures 3

Clinical Pearls

• Apixaban has demonstrated superior efficacy compared to warfarin in stroke prevention for atrial fibrillation patients, with reduced risk of major bleeding 2
• No routine coagulation monitoring is required 2
• The short half-life (12 hours) means missed doses can lead to periods without adequate anticoagulation protection 2
• Studies show that prescribed doses don't always follow recommendations, particularly in treatment-naïve patients 4
• For VTE treatment, it's crucial to use the higher initial dose (10 mg twice daily) for the first 7 days before transitioning to the maintenance dose 1, 3

Remember that the appropriate dosing of apixaban is essential for balancing efficacy in preventing thrombotic events while minimizing bleeding risk.